Perceived benefits of geriatric specialty telemedicine among rural patients and caregivers

Abstract Objective Explore the perceived benefits of a Veterans Health Administration (VHA) geriatric specialty telemedicine service (GRECC Connect) among rural, older patients and caregivers to contribute to an assessment of its quality and value. Data Sources In Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits. Study Design A cross‐sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges. Data Collection We conducted 30 semi‐structured qualitative interviews with rural, older (≥65) patients enrolled in the VHA and their caregivers via videoconference or phone. Interviews were recorded, transcribed, and analyzed using a rapid qualitative analysis approach. Principal Findings Participants described geriatric specialty telemedicine visits focused on cognitive assessments, tailored physical therapy, medication management, education on disease progression, support for managing multiple comorbidities, and suggestions to improve physical functioning. Participants reported that, in addition to prescribing medications and ordering tests, clinicians expedited referrals, coordinated care, and listened to and validated both patient and caregiver concerns. Perceived benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow‐up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age‐Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi‐complexity). Conclusions Alignment of patient and caregiver experiences with widely‐used models of comprehensive geriatric care indicates that high‐quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.

benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow-up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age-Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi-complexity).
Conclusions: Alignment of patient and caregiver experiences with widely-used models of comprehensive geriatric care indicates that high-quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.
geriatrics, referral and consultation, rural, telemedicine, veterans health

What is known on this topic
• Telemedicine has the potential to increase access to geriatric specialty care, particularly for older adults living in rural areas.
• While there was a rapid expansion of telemedicine during the COVID-19 pandemic, there is limited research on the quality of geriatric care delivered via telemedicine.
• Age-Friendly Health Systems and the Geriatric 5Ms are models of comprehensive, high-quality geriatric care, but it remains unclear how these models translate to virtual care delivery.

What this study adds
• Perceived benefits of GRECC Connect (geriatric telemedicine) included positive impacts on patients' health and coordination of care in addition to providing support for and building the confidence of patients and caregivers.
• Patients' and caregivers' perceptions of the content and benefits of the GRECC Connect geriatric telemedicine service are well-aligned with the Age-Friendly Health Systems model and Geriatric 5Ms framework.

| INTRODUCTION
While many people in the United States face challenges accessing health care services, it is especially true for the fifth of the population who live in rural areas. 1,2,3 Compared to urban populations, those in rural communities tend to be older and in poorer health 4 and face numerous barriers to health care access, including a paucity of hospitals, clinics, and health care clinicians and a lack of transportation options. 1,2,5,6 Telemedicine is a promising solution to many of these barriers. 7 Rural, older adults, in particular, could benefit from telemedicine given the shortage of geriatric specialists in rural areas 6,8 and likelihood of this population facing barriers to travel related to mobility, vision, and cognitive challenges. 9 Although there has been recent rapid growth in telemedicine catalyzed by COVID-19 restrictions on in-person care, 10 telemedicine utilization has historically been low, 11,12 particularly among older adults. 13 For some, the ritual of in-person care 14 is closely tied to high-quality care and is believed to provide the basis for building patient-provider rapport and medical trust. 15 This leads some patients and physicians to question if high-quality care can be provided virtually. 13,16,17,18 Many of the same characteristics that make travel to in-person medical visits difficult for older adults (e.g., hearing, vision, and cognitive impairment) can also make it more challenging to access care virtually. 19 Furthermore, older adults may be less likely to have the technological devices or literacy needed to successfully participate in virtual medical visits. 20,21,22 This has been the impetus for research focused on acceptability, 13,23 usability, 19 and facilitators and barriers to implementation 24 of geriatric telemedicine. While these studies of feasibility are necessary, the Technology Acceptance Model suggests that perceived usefulness among end-users is also critical for determining the value of an alternative model of care delivery. 25,26 Two systemic reviews support the general feasibility and acceptability of telemedicine among older adults, but call for more research to be done on the quality of telemedicine care for this population, 27 especially for those living in rural areas since the existing, limited data are mixed. 28 A recent study focused on perceived benefits of geriatric telemedicine by patients and clinicians during the COVID-19 pandemic reported divergent views on its usefulness and concluded that quality of care for some older adults suffered. 16 It is challenging to tease out participants' perceptions of the content of the visit versus the modality-indeed, they sometimes overlap-yet this is the type of understanding that is needed to create meaningful post-pandemic policies that will sustain or even expand high-quality telemedicine for older adults in the future. 10,29 Judgments of quality of care may depend on the type of health care visit. Age-Friendly Health Systems aim to provide older adults with evidence-based care aligned with their health care preferences and goals, making this model appropriate for assessing geriatric care visits. 30 Many experts consider the 4Ms framework of the Age-Friendly Health Systems model-Medication, Mentation, Mobility, and what Matters most-as well as Multi-complexity as a 5th M in some expanded models 31 -to be an essential part of comprehensive, quality geriatric health care. 32 Using a 5Ms framework means providing care for older adults that aligns with their goals and preferences and focuses on medications (e.g., polypharmacy concerns, how their use interacts with the other 4Ms), mentation (e.g., mood and cognition), mobility (e.g., gait and ability to safely move about their environment), and multi-complexity (i.e., acknowledging and addressing the often complex intersectionality of multiple chronic and acute ailments and social context). 33 To our knowledge, there are no published studies on how this framework translates to the virtual environment, though some literature outlines its potential. 34 The Veterans Health Administration (VA) has long relied on telemedicine to care for 2.7 million rural Veterans, 35 among whom more than 55% are aged 65 or older. 36 The GRECC Connect program,

| Study design
We conducted a cross-sectional qualitative evaluation with patients and caregivers who had participated in at least one GRECC Connect telemedicine visit within a 3-month period prior to the interview.

| Study team
The overall evaluation team consisted of nine VA researchers with expertise in program evaluation, qualitative methods, implementation science, and geriatric medicine, as well as a Veteran research consultant with experience providing technical assistance to older adults.
The subgroup of this team that conducted the interviews was headed by an anthropologist (Eileen M. Dryden) with over 25 years of experience leading qualitative research and evaluation studies and included three master's prepared health services researchers with substantial experience in public health and qualitative methods (Chitra P. Anwar, Jacqueline H. Boudreau, and Jennifer Conti). For the analysis phase, the group was expanded to include a fifth team member, a physicianscientist (Meaghan A. Kennedy), who provides primary care for and conducts mixed-methods research focused on older adults.

| Setting
In December 2020, we sent letters to the clinical leads of seven of the 15 GRECC Connect hubs to serve as recruitment sites. We selected hubs that were geographically diverse and had a high enough volume of patient encounters to support recruitment.

| Interview participants
Interviewees were recruited from lists of patients who completed GRECC Connect telemedicine visits between December 2020 and March 2021.
We defined "telemedicine visits" as (1) video visits conducted between a remote geriatrics specialist and a patient at home (VA Video Connect [VVC]) or at a community-based VA clinic (Clinical Video Telehealth [CVT]); or (2) telephone visits conducted between a remote geriatrics specialist and a patient at home. Prior to initial contact, three team members briefly reviewed each patient's electronic health record (EHR) to determine the telemedicine visit date and modality and screen for eligibility. Patients were eligible for participation if they were ≥65 years old, resided in a rural area (rural-urban commuting area code [RUCA] >1), 37 participated in a video or telephone GRECC Connect appointment between December 2020 and March 2021 and spoke English as their primary language. We aimed to interview 30 participants; a sample large enough to reach "meaning saturation," 38 that is, to provide a range of experiences and sufficient rich, detailed qualitative data to understand the topic of study, yet small enough to feasibly implement within the study scope and timeframe.
Female and non-White patients were contacted first in an effort to oversample these participants in a largely White, male population of older, rural Veterans. Gender and race were identified through patients' EHR.

| Recruitment
We recruited our sample via mailers and then by telephone. Prior to interviews, an evaluation team member performed a brief phone screening with the patient and/or the patient's caregiver to confirm recall of a specific GRECC Connect telemedicine appointment ("index appointment") around which to ground the interview. To enhance their ability to recall the appointment, we chose to limit recruitment to individuals with an index appointment within the 3-month period prior to the interview. Once participants consented to participation, a study team member performed a detailed chart abstraction of the patient's EHR using a structured template. Information from chart abstractions was integrated into a visual appointment summary that depicted, in lay language, the content discussed and outcomes (e.g., referrals or medication changes) of the index appointment.

| Data collection
Four experienced qualitative researchers (Chitra P. Anwar, Jacqueline H. Boudreau, Jennifer Conti, Eileen M. Dryden) conducted semistructured qualitative interviews with participants via videoconference or phone. In cases where patient participants had some degree of cognitive impairment (e.g., dementia), we interviewed the patient-caregiver dyad ("the dyad"). While the interview included questions concerning experience with the technological aspects of the visit (manuscript in progress), the questions that are the focus of this manuscript explored patient and caregiver perceptions of visit content (i.e., the focus of and activities that occurred during the visit) as well as perceived benefits, challenges, and impact. This included questions about changes the dyad experienced as a result of the visit (e.g., in diagnosis, medications, activities, support services), including differences in health, physical or emotional well-being, and ability to take care of things at home. We also asked about satisfaction with the visit and their recommendations to improve the quality of the visit. A shareable visual appointment summary was used to facilitate recall and provide a shared conversational reference for the interviewer and interviewee(s). 39

| Data analysis
Interviews were recorded with permission and transcribed verbatim; transcripts were then reviewed to verify accuracy. All interviews were analyzed by a team of five experienced qualitative researchers (Chitra P. Anwar, Jacqueline H. Boudreau, Jennifer Conti, Eileen M. Dryden, Meaghan A. Kennedy) using a rapid qualitative analysis approach. 40,41 Once all interviews were completed, analysts summarized individual interviews using a structured template, meeting regularly to develop consensus about domains, which included a priori and emergent domains from the semi-structured interview guide and interview content. To develop consensus and consistency in the application of the structured template, two interviewers summarized two initial transcripts and three reviewers reviewed the summaries. Ten additional interviews were summarized in rotating pairs or triads. The remaining transcripts were summarized individually, with all analysts meeting regularly to resolve uncertainties or refine content domains. Summary templates were condensed into a single matrix where each row represented a participant/dyad and each column a domain, to allow for summarizing findings within and across domains. The analysis team identified common, unique, and salient themes in the data and reviewed them, along with illustrative quotes, with the larger evaluation team. The larger team included GRECC Connect leadership and physicians, as well as a primary care provider, and other evaluators of geriatric services. This group of content and methodological experts provided context for and helped to interpret the findings.

| Ethics
This work was determined to be quality improvement/evaluation by the VA Bedford Healthcare System Institutional Review Board (IRB), and therefore not subject to IRB approval and oversight as human subjects research.

| RESULTS
Of the seven hub sites invited to participate in the evaluation, one site declined, citing a lack of staffing capacity to generate patient lists from which the evaluation team could recruit. We sent mailers to 110 individuals associated with the remaining six hub sites; 19 people called to opt out of recruitment. We attempted to contact the 91 remaining patients by telephone but were unable to reach 31 of them. Of those we reached, 25 declined to participate and we were unable to find a time to schedule an interview with five of them. Our final sample included 30 Veterans. Interviews ranged from 45 to 60 min in length. Fiftyseven percent were conducted by VVC, a VA-approved videoconferencing platform, 40% were conducted by telephone, and one was conducted by a combination of VVC and telephone.

| Participants
Patient participants (n = 30) were all male; 96% were White, non-Hispanic, one participant was White, Hispanic, and one was unknown.  Table 1 for Index visit characteristics.) Nineteen (63%) of the interviews were conducted with dyads.

| Visit satisfaction
Patients and caregivers were largely satisfied with GRECC Connect, and many said they would recommend GRECC Connect to other patients. Overall, participants found the GRECC Connect clinicians (both individually and in teams) to be thorough, professional, competent, and responsive to their needs. Some participants voiced dissatisfaction owing to unmet expectations related to the purpose or the process of the visit. For example, a dyad was skeptical that an Alzheimer's diagnosis could be determined based on "a few questions" conducted virtually and worried whether the visit purpose was inappropriate for telemedicine. Ultimately, the process of doing this assessment and making the diagnosis was unsatisfactory for this dyad.
"I thought maybe they would do more testing, asking questions [like], you know, "remember this and remember that," and that did not happen. They just listened to what we had to say [and] then diagnosed him with this. (…) I just need to know how they came to this conclusion without any testing. This is the hard part for me to understand." Caregiver E -Site 1.

| Benefits associated with the visit
Patients and caregivers described a number of perceived benefits of GRECC Connect telemedicine: improved health for the patient; increased knowledge and confidence; and feeling empowered, hopeful, and supported.

| Improved health for the patient
Patients and caregivers reported improvements in physical and cognitive health due to medication changes (i.e., prescribing, deprescribing, changing dosage); education about the importance of certain treatments and their impact on memory (e.g., leading to more consistent use of a CPAP machine and oxygen); more consistent access to tailored physical therapy; and safer environments due to reduced fall risks in the home. Improved health outcomes attributed directly to these activities included lower blood pressure, better quality sleep, improved memory, fewer falls, less confusion, and less anxiety. The following was noted by a caregiver and corroborated by the patient: "I really think since he's been taking this pill he's resting at night better. His anxiety is less and he seems to be remembering things a little better (…) I think that him resting-not just, you know, sleeping but really resting -I think that's helped him." Caregiver B-Site 2.
Some caregivers noted changes in the patient's health translated to better health for them as well. For example, some noted that once the patient was sleeping better, they slept better, too.

| Increase in patient and caregiver knowledge and confidence
Participants noted the evaluations, diagnoses, updates on the progression of illness, and education around managing symptoms increased their knowledge and confidence. For some, these visits confirmed what they felt they already knew but they appreciated the information and felt validated. Others said they really had 'no idea what was going on' so a diagnosis during the telemedicine visit provided a new understanding. Many described getting clarity around the patient's mental and physical state during the visit, and for some, that put them at ease. There are so many things they helped me with (….) (For example,) the doctor gave me a good way to deal with him when he gets upset. Told me to touch him lovingly, tell him, "Hey, I know you're upset. It'll be okay," and it works." Caregiver C-Site 1. Multi-complexity • Care Coordination • Education around treatments/medications for one disease affecting symptoms of another • Connecting patient well-being with caregiver wellbeing "You know, (they said), if you wear your oxygen, you know, you are gonna remember more, and believe it or not he has said to me, "You know, hey, I think this might be working a little bit 'cause I remember a little bit more' and he has. I noticed a difference (…)." Caregiver D-Site 5 this made them feel like they were part of a team. Knowing there was someone to call if they needed something also made many of them feel more confident.
"I don't feel so alone now, and I think that he's doing a little better." Caregiver E-Site 4.
Many patients and caregivers described GRECC Connect clinicians spending time simply listening to their experiences, fears, and concerns about their mental and physical health, answering questions, and sharing their knowledge and expertise. These actions made patients and caregivers feel validated, confirmed their suspicions, made them feel supported and cared for, helped normalize their experience, and assured them that "they were doing things right." "It really makes us both feel better (…) It's just helpful to know that somebody's out there that cares, I guess." Caregiver B-Site 1.

| Alignment with the geriatric 5Ms
During the interviews, participants were asked about the focus of activities that occurred during the telemedicine visit. While these are discussed above along with associated perceived benefits, it is notable that the most salient aspects of the visits aligned with the Age-Friendly Health Systems 4Ms framework (plus the 5th Multicomplexity domain). See Table 2

| DISCUSSION
Telemedicine is a potential solution to the barriers many rural, older adults face accessing in-person specialty care. 6,8,9 Because much literature exists that demonstrates the feasibility and acceptability of the virtual modality for older adults, 13,19,23,24,27 we chose to focus this work on the content of geriatric telemedicine visits to explore whether high-quality geriatric care could, in fact, be delivered virtually.
Overall, patients and caregivers were highly satisfied with GRECC Connect telemedicine. focusing on what can be done, as patients and caregivers in our study described that this made them feel more empowered and hopeful.
Despite these challenges, our findings demonstrate it is possible to deliver high-quality geriatric care virtually to older adults. It is important, however, to recognize the uniqueness of the GRECC Connect program. This program, established six years before the onset of the COVID-19 pandemic, has invested substantially in the geriatric telemedicine service and ongoing evaluation and quality improvement. 45,46,47 This VA national network of experts functions as a learning collaborative, meeting regularly to share lessons learned and best practices. The experience they have gained over the years has not only gone into improving their own practice but is available to others via recorded educational workshops, conference presentations, and toolkits. 48,49 These resources may help those who are new to geriatric telemedicine provide similar, high-quality health care to their patients.
The findings of our study are limited by the small sample of older patient participants who were all White and male, despite attempts to recruit a more diverse group of interviewees. This is, in part, because most rural Veterans served by the VA are White and male, 50 but may also be attributable to racial and socioeconomic disparities in telehealth use. 51,52 By virtue of our study objectives, we included only patients and caregivers who had participated in a telemedicine visit.
Study participants likely differ in many ways from older, rural adults and caregivers who are unable or unwilling to engage in telemedicine.
Rural, older adults are less likely to have reliable Internet 52 and more likely to have sensory and cognitive impairments that impede the use of telehealth. 19 Additionally, this population is less likely to have the technological devices or literacy needed to successfully participate in virtual medical visits. 20,21,22 Therefore, additional research is needed not only to address the challenges identified to continue to improve geriatric telemedicine but to also ensure high-quality geriatric care reaches all those who could benefit from it.